How to manage high fever, headache, and photophobia with NSAIDs?

STOP: Rule Out Meningitis Immediately

This patient requires urgent evaluation for bacterial meningitis before any treatment with NSAIDs—the combination of high fever, headache, and photophobia represents a classic triad that demands immediate lumbar puncture, blood cultures, and empiric antibiotics if meningitis cannot be excluded. 1

Critical Red Flags Present

• Fever + headache + photophobia = meningitis until proven otherwise
• Using NSAIDs to lower temperature in this context is dangerous because it masks a critical diagnostic sign (fever) and delays life-saving treatment 2
• The anti-inflammatory effects of NSAIDs diminish the utility of fever as a diagnostic sign in detecting serious complications 3

Immediate Actions Required

Before considering NSAIDs for symptom management:

1. Perform urgent neurological examination looking for:

   • Neck stiffness/meningismus
   • Altered mental status
   • Focal neurological deficits
   • Kernig's or Brudzinski's signs 1

2. If any meningeal signs present or patient appears toxic:

   • Obtain blood cultures immediately
   • Perform lumbar puncture (unless contraindicated by signs of increased intracranial pressure)
   • Start empiric antibiotics (ceftriaxone + vancomycin) before LP results if any delay anticipated
   • Do NOT give NSAIDs until bacterial meningitis excluded 1

3. If examination is completely normal and patient is well-appearing:

   • Consider alternative diagnoses (migraine, viral syndrome)
   • Proceed with symptomatic treatment as outlined below

If Meningitis Excluded: NSAID Management Approach

Only after ruling out serious pathology, NSAIDs are appropriate for fever and headache management:

For Fever Control

• Ibuprofen 400-800 mg orally every 6 hours (maximum 2400 mg/day) is the preferred first-line NSAID for fever reduction 2
• Alternative: Naproxen sodium 275-550 mg every 6-12 hours (maximum 1500 mg/day) 2
• Acetaminophen 1000 mg can be added for synergistic effect, but is less effective as monotherapy 2, 4

For Headache (If Migraine Suspected)

• Combination therapy: Aspirin 650-1000 mg + Acetaminophen 1000 mg + Caffeine is more effective than NSAIDs alone for moderate-to-severe headache with photophobia 2
• If nausea present: Add metoclopramide 10 mg orally or IV for synergistic analgesia and symptom control 2, 1
• For severe headache not responding: Ketorolac 60 mg IM (if under 65 years) provides rapid onset with 6-hour duration 2, 1

Critical Monitoring Parameters

• Limit NSAID use to no more than 2 days per week to prevent medication-overuse headache 2, 1
• Monitor for GI bleeding risk, especially with prolonged use (>5 days for ketorolac) 2, 3
• Reassess if fever persists beyond 48-72 hours or if new symptoms develop (neck stiffness, confusion, rash) 1

Common Pitfalls to Avoid

• Never suppress fever with NSAIDs in undifferentiated illness without excluding bacterial infection 3
• Do not use opioids for headache management—they cause dependency and rebound headaches 2, 1
• Avoid acetaminophen monotherapy for migraine—it is ineffective without combination therapy 2
• Do not exceed maximum daily NSAID doses: ibuprofen 2400 mg, naproxen 1500 mg, ketorolac 120 mg 2